I work in a primary care office which also functions as walkin-care. There are three NPs in the office and we work 12 hours a day usually with two nurses. Last week, we had a really busy day. Patients were coming in waves, as always towards our closing time we had four patients checked in. I was 45 minutes behind at that time. Anyway, one of the patients came in for tick bite, and tick was still attached. I removed the tick. She was a young woman and was very distraught about the tick bite. She asked if we can check her body for other ticks because she lives alone. It seemed a reasonable request even though we don't usually have patients ask this.
Because I was already running late and I had one more patient to see, I asked the nurses ( one LPN, one RN) if they can check her for ticks. Both of them flat out refused, saying that:"we don't do that in this office", "I don't feel comfortable doing it".
I was really appalled and exasperated that they were refusing my request. Both of the nurses are very competent and good at their jobs. I had no prior issues with them. Anyway, I ended up doing it. As a result, I left the office more than one hour after closing and with some open charts for the next day because I was just exhausted. Both of the nurses were gone at this point.
When we are really busy, I do my own swabs, wound care etc. As a NP we can still do what nurses do, but they cannot do our jobs. I don't want to create a toxic environment but I strongly feel that this behavior should be discussed.
Now, I want to address this issue when I return to work on Monday. I don't think I am being unreasonable. I would like your input on how to address this with them. We have an interim practice manager who is overworked and a nurse manager about leave in two weeks. I don't want to necessarily escalate to upper management since these nurses are most of the time do pretty good job.
Last edit by Brian S. on Jun 5
Genuine honesty is the best approach. Start off by saying you appreciate all their hard work, then address your concern. Be sincere, don't get emotional and keep the atmosphere conversational. Bottom line, you need to know that you can delegate appropriate tasks to them and this was not outside of their scope of practice. Think about it this way: if the roles were reversed, how would you want the NP to approach you about this?
As stated, being up front about these situations and laying out responsibilities is important. I generally all politely things If my staff, but If I pick up a "not my job" vibe and it is then I will make sure there's office manager involvement. If they need a clear delineation of duties though, I don't let my RN background pick up their slack. I'll expect them to do each duty to the tee. I'm more than flexible until people lay down ultimatums and leave when there's work to be done still.
I would seek clarification with management and the RNs because that is well within their duties. Maybe it was them being uncomfortable alone with a naked patient and should have been suggested as a chaperoned activity if it wasn't? The other thing and I am not in any way interested in doing RN duties but since this is an uncommon situation and she was already sitting on your exam table a quick once over probably would have taken less time for you to just do it and document than finding the RNs and asking them to do it.
Had I objected, it would have been for the reason Jules mentioned, being uncomfortable at being alone with an unclothed patient without another staff member present. I would not have objected because of a perceived "attitude".
I guess I should clarify. I removed the tick from her lower leg and she was fully clothed. When she asked if we can check her for other ticks, I told her I need to go see the next pt. The she said I am OK if one of the nurses checks me for ticks. So,I gave her a gown to put on and exit the room to ask the nurses. She was only asking for her back and her neck area to be checked, no private parts or front of her body. Yes it would be a quick glance if she was already undressed. Also, nurses are thought to do skin assessment on patients in the nursing school. This wouldn't be much less involved than a skin assessment. Both of the nurses were females also. In any case, I felt unsupported by my team, this is why it is an issue in my opinion. Thank you for your inputs though. Always good to look at things from different perspective.
If you had a patient come in with a tick, why wasn't at least a cursory skin check done automatically during your initial exam?
There are different types of leadership, one will keep you fighting for every inch, the other will gain you respect and camaraderie.
As I pointed out she was not undressed and I had another pt waiting to be seen. I see your point though
Were the other staff male or female? As a male I totally would not do that without another staff member present. Is it possible there is a clinic policy about this as the reason why they were refusing/uncomfortable?
well its 2018 gender shouldn't have anything to do with it unless the patient specifically asked for a female but my question would be what if the RN was to do it and they missed something then would it fall on the NP or the RN. Is this really within the RNs scope of practice in this type of setting and situation?
I'm not entirely sure it's the tick inspection itself they are objecting to, even though they said they were uncomfortable with it. The way you described your workplace, OP, sounds as though everyone is drowning in work. The tick inspection might have been the straw that was going to break someone's back, no matter whose.
When ordinarily hard-working people start refusing work or arguing about work load, it generally means there's just too damn much of it. Unless you get more attitude than cooperation when you delegate other things, this may have just been a one-off. Sounds like the bigger issue is you need additional help in your office.
When someone tells me that they are not comfortable performing a task, I ask them if they would like to watch and assist me with the task. If at that point they flat out said no I would have left it alone at that time to keep moving forward with patients. Later, I would have asked for further clarification as to why they did not want to learn the new task.
I used to work urgent care and 12 hour shifts at that, so my assumption is that they just wanted to get home.
As you might know, nursing as a profession harbors a lot of people who do not feel comfortable doing what they do not "usually" do, whatever the circumstances. You named the assessment "tick check" and the nurses might be immediately put off by it simply because, well, they really never did "tick check" before. They did "skin assessment", which is essentially the same thing, but the business is in the name.
They also might know something about that particular patient that you don't know yet, if they work there long enough.
Or they just fed up and wanna go home for whatever it takes.
I wouldn't do such an assessment, even as a glance, without another person, preferably same gender as the patient, in room. Otherwise, I would follow DowntheRiver advice but later ask the most senior staff what's up about the patient.
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